Standardisation of Provision of Assistive Devices in South Africa

Rehabilitation for all - National Rehabilitation Policy

Standardisation of Provision of Assistive Devices in South Africa

A Guide for use in the Public Health Sector

Contents

Minister's Forward

SECTION 1

Introduction

Significance of Assistive Devices for Peoplewith Disabilities
The Epidemiology of Disability in South Africa

SECTION 2

Budget for Assistive Devices
Assessment, Prescription and Ordering ofAssistive Devices
Issuing of Assistive Devices
Repairs, Replacement and Recycling ofAssistive Devices
Payment for Assistive Devices and Accessories
Free Assistive Devices for Children under six
Record-keeping of Assistive Devices
Training in the use of Assistive Devices
Stocks of Assistive Devices and Accessories
Custom-made and Self-made AssistiveDevices
Motorised Wheelchairs
Alternative and Augmentative Communication(AAC)
Personal Assistants
Inclusions in Tenders for Assistive Devices

ACKNOWLEDGEMENTS

APPENDIX A

Acronyms

Section 1

Foreword

It gives me great pleasure to present the national guideline on the Standardisation of Provision of Assistive Devices in South Africa.

As government we have a commitment to improve the quality of life of people with disabilities in this country. We are fully aware that people with disabilities are among the poorest and the most vulnerable groups in society. They are often denied access to education and training, which in turn results in lack of skills that are necessary for employment.

An assistive device opens doors to learning, employment and social participation. There is always a possibility of viewing people with disabilities as a homogeneous group, all requiring the same kind of intervention and the same type of device. The reality is that people with disabilities are as diverse as society itself, each with their own unique contributions and requirements.It is my firm belief that this document will provide the policy framework which will ensure that the provision of assistive devices is equitable and appropriate. The document will also place an obligation on service users to ensure that the devices are properly cared for.

It is our contention that even devices that are known to break down easily can last longer if properly cared for. We are positive that no matter how big the challenge of providing services to our people seem, at the end we will make a difference.

I want to take this opportunity and salute all those who were involved in the process of developing this document, both from government and civil society organizations. A special word of thanks goes to the Technical Committee members who worked so tirelessly to make this dream a reality. To all of you I say well done.

Section 1

Introduction

For people with disabilities, an assistive device promotes a normal lifestyle, improves their quality of life and enhances the prospects of employment, education and participation. Simultaneously, it reduces the cost of care and dependency. Devices reduce the extent of hospitalisation, as well as the demand for hospitalisation, and therefore liberate scarce resources for other uses.

Even more important are the political and moral benefits: the general availability of devices has been proven to promote the dignity of people with disabilities and transform attitudes towards them.

This guideline puts forward proposals that will have a direct, practical benefit for people with disabilities with due consideration to cost implications to the State.

1. Significance of Assistive Devices for People with Disabilities

Assistive devices (ADs) are key mechanisms by which disabled people can participate as equal citizens within society. The World Programme of Action (WPA) concerning disabled persons (UN, 1982) outlines three areas of importance, viz. prevention of disability, rehabilitation and equalisation of opportunities, that need to be addressed. Included in rehabilitation is the provision of measures intended to compensate for a loss of function or functional limitation - one of these being through technical appliances. It is also recognised that a precondition for the equalisation of opportunities is the provision of support services to disabled people.

Assistive devices should include those that:

promote the independence of a disabled person;
contribute to disabled people functioning in society;
facilitate communication for disabled people; and
improve the quality of life of disabled people.

An assistive device is both impairment-specific and person-specific.

2 The Epidemiology of Disability in South Africa

In order to estimate the number of disabled people requiring assistive devices, it is necessary to examine the epidemiology of disability. This is a difficult task because baseline data on disability prevalence is not readily available. Prevalence studies on disability in South Africa have used different definitions of disability which makes comparison of disability rates problematic.

Most of the prevalence studies on overall disability in South Africa have used a two-stage methodology for self- (or proxy-) reported disability and confirmed medically diagnosed impairment. The disability survey by the Department of Health (DoH) (1999) was a one-stage study for self- and/or proxy-reported disability.

A further complication is that results related to reported disability need to be carefully interpreted. For example, reported motor disability may only be an indication of a subjective manifestation of difficulty with body functions.

In order to estimate the prevalence of need for assistive devices, an attempt has been made to combine estimates from the available disability prevalence studies for three impairment/disability types:

visual (blind and visually impaired people)

communication (speech, voice, language disorders, hearing disorders and deafness)
motor (movement, mobility, locomotor)

It is important to clarify and emphasise that the overall crude rates only provide a rough indication of the need for specific assistive devices. In order to determine the exact prevalence of need for assistive devices, specific studies should be performed.

Crude prevalence rates are given where age/sex-specific adjusted rates are not available. The non-availability of adjusted rates makes the comparison of prevalence rates in different areas or from different studies difficult. This is further compounded by the variation in the prevalence of different disabilities according to age and sex.

The national disability study (DoH,1999) gave an overall crude prevalence rate of 2.0% for reported movement disability, 1.7% for reported moving around disability and 1.8% for reported activities of daily living disability.

Composite Table: Crude Prevalence Rates for Visual, Communication and Motor Impairment in South Africa

In conclusion, this section has outlined the need for assistive devices in South Africa. Existing literature was reviewed in terms of available prevalence rates which could be used to assess the extent of the need for assistive devices for visual, communication and motor impairment. Only very rough estimates can be made using the available data. Specific studies are required to refine the data and obtain age-adjusted prevalence rates which can be used to indicate the cost implications of the provisioning of assistive devices in South Africa.

Section 2

Principles Regarding Assistive Technology

The unavailability of ADs causes a high degree of dependency or even total dependency. It might also lead to the waste of time and money by training institutions because the acquired skills by professionals are not practiced and applied and the client relapses into dependency again. In most cases these ADs enable persons to enter the labour market. The devices are therefore essential for independent living, education and participation in social life.

The following are principles for the provisioning of the necessary assistive devices by the public sector:

1. Budget for Assistive Devices

A budget allocation applicable to all categories of ADs should be promoted at provincial and regional/district level. Budgets should be based on local needs and should also provide for any backlog that may have accumulated in each province. Input should be obtained from relevant rehabilitation providers regarding decision-making and planning for budgets and tendering for ADs. Professionals directly involved in issuing ADs should be involved in the budgeting, tender and procurement processes.
The actual (realistic) need for ADs, taking into account the effect of replacement, repair and maintenance of ADs, must be budgeted for.
A budget to supply a specified number of ADs for short-term loan and rental purposes must be available.
A standardised record system of ADs that are prescribed, issued, repaired, replaced and recycled must be kept to facilitate budgeting. The date on which a client receives an AD, and the expected date of replacement, should be logged in, in detail.
Accessories for ADs and non-tender wheelchair accessories and items (e.g. gloves, commodes, etc.) should be budgeted for at relevant levels.
Special funds or donations for ADs:
- The recipient authority should establish a committee of relevant rehabilitation personnel, both administrative and clinical, to manage the funds/donated ADs.
- ADs accepted as donations should at least adhere to international and/or SABS endurance standards where possible, and be appropriate for the South African environment.
Home-made ADs and materials for these items must be obtainable via the supplies budget at all levels of the health system.
Adequate provision must be made for larger quantities of items that need regular replacement (high-wear and tear items).

2. Assessment, Prescription and Ordering of Assistive Devices

There shall be no discrimination against clients on the grounds of disability, age, gender, social conditions, financial situation, disease, medical condition, or any other basis in the assessment for issuing an AD.
Assessment and prescription for ADs shall only be done by appropriately trained rehabilitation providers. Once the selection has been finalised, the same professional or assistant should issue the device and provide the necessary training.
Prescription forms for an AD shall not have to be co-signed by a medical practitioner or medical superintendent. The prescription should be co-signed by individual department heads who are more readily available and knowledgeable.
Only speech therapists may evaluate, assess, diagnose and treat patients with feeding and/or swallowing problems.
Assistive devices for hearing impairments should be prescribed, fitted and issued by audiologists, hearing-aid acousticians, audiometricians or any other appropriately registered category only.
Newly trained graduates should be specifically trained in the issuing of ADs after the commencement of employment.
Newly developed assistive devices are to be considered for addition to the Government Tender.

3. Issuing of Assistive Devices

The client should be issued with the required AD by the institution/organisation discharging the client to his home (i.e. the facility providing rehabilitation to the client) or the referral facility doing the rehabilitation.
The AD should be issued immediately when prescribed or, at the latest, on discharge.
All persons with a disability where the sensory functions are affected (e.g. paraplegic/quadriplegic) shall be discharged from hospital with the basic assistive technology requirements (viz. an appropriate wheelchair, wheelchair cushion and mattress).
Instant access to assistive devices for infants, children and adults with feeding and swallowing difficulties, e.g. cleft palate, stroke and cerebral palsy, should be guaranteed.
First-time issue of ADs should only be done by the appropriately trained rehabilitation provider who prescribed the item or an appointed substitute.
Establishments other than health facilities should be allowed to issue ADs subject to prior arrangements with the Health Authority (Private-Public Partnership (PPP) or contracting out of service).
Alterations of ADs should only be done by an appropriately trained provider. A standardised contract should be drawn up and signed by the client before or on issuing of the AD, stipulating that the AD will be returned to the issuing institution if no longer required and that it remains the property of the state/provider.
A limited number of ADs for loan or rental purposes shall be made available at all health facilities for persons with disabilities. If the particular facility cannot provide this service, it should be contracted out or a PPP can be established

4. Repairs, Replacement and Recycling of Assistive Devices

High wear and tear items should preferably be replaced by trained rehabilitation providers (or other staff members). However, where appropriate, clients should be trained to replace such items.
Specialist repairs, e.g. for Braille watches, should be made available to users.
Repairs under warranty should be dealt with according to business principles.
The establishment should ensure that repairs are done by qualified/trained persons.
Records of repairs should be kept to facilitate budgeting and to control repairs.
The expected life-span of an AD should be indicated by the manufacturer or supplier.
There should be no limits on the replacement of an AD unless it is not needed anymore, or there is evidence of poor maintenance or abuse.
If possible, replacements should be done by the issuing establishment, as a condemning report will be required if a device cannot be used any longer.
Repairs should be done on a “fix-while-you-wait” basis or at least within three days.
High-cost ADs requiring replacement should be evaluated for recycling.
In the case of the AD being re-issued to another client, the AD should be fully serviced and supplied with new parts, where deemed necessary, by a trained technician before issuing. These repairs should be paid for by the facility that owns the AD.
Repairs to ADs should be included in the tender (service tender). This will enable provinces to operate within a dedicated repairs budget.
Old usable Ads, e.g. spectacles and hearing-aids, are to be recycled.
Devices that are not utilised shall be retuned by the client for recycling.
The facility that issued the device should take responsibility for making repair arrangements. Where possible, this arrangement should ensure that the closest establishment to the client assists with repairs.
ADs should be replaced only for the following reasons (accompanied by proof wherever possible):
- All clients should be re-assessed every two years and ADs replaced if necessary where the client's condition deteriorates/changes to the extent that replacement is necessary.

Where the life-span of ADs and accessories has been completed.

Recycled items may need replacement sooner than new items and therefore record-keeping is essential. The original worn-out item should accompany the request for replacement. The relevant staff member should take possession of the worn-out item to prevent repetitive submission of the same item for replacement. Such items should then be destroyed. When clients apply for the replacement of stolen items they should provide an appropriate South African Police Service case number. ADs will be replaced free of charge while still under warranty if the malfunction is not the result of negligence or abuse on the part of the client. Subsequent issue of ADs as a result of wear and tear or breakage could be by a different provider if the user presents the old AD with the relevant specifications, e.g. sizes, numbers, etc.

5. Payment for Assistive Devices, Accessories and Maintenance

Payment for assistive devices should be done according to a Uniform Patient Fee System (UPFS).
The same will apply to accessories and maintenance.
Refunding should be done if the item is returned and can be re-utilised. ADs will only be refunded where the funds recovered justify the administrative burden.
Cross-border payment arrangements shall be put in place.

6. Free Assistive Devices

Assistive devices should be part of the service package offered free of charge to qualifying members e.g. children under six and disabled people qualifying for free health care.

7. Record-keeping for Assistive Devices

A record of all applications for ADs should be kept with the client's particulars (age, name, address, file number, type, specifications of AD and patient classification).
The serial number or an appropriate description (including for example colour, size, type) and expected life-span of the AD should be recorded on issue. Items with a short life-span or inexpensive items need not meet this requirement.
In the case of long-term ADs, the name of the place where the AD was issued should be indicated on the AD if possible.
Records should be kept of repairs/maintenance and AD replacement.

8. Training in the Use of Assistive Devices

Training/rehabilitation should be done by an appropriately trained rehabilitation provider. This is necessary to ensure that the client gets the full benefit of the device and that he/she knows how to maintain the device, as well as when and where to take it for repair.
The training/rehabilitation regarding the AD usage should be inclusive in the payment for the device.
Rehabilitation should start immediately and discharged should not be delayed unnecessarily. This will ensure a cost-effective service.

9. Stocks of Assistive Devices and Accessories

For bulk buying care should be taken that adequate numbers of different sizes of ADs and the relevant spare parts are purchased.
In the case of prescription glasses, at least two options for frames should be available for men, women and children. Ready-made glasses (low cost glasses), in the ranges most often prescribed, should be stocked at all times.
Stocks should be kept at various levels of health care services.
Suitable storage security and stock control should be maintained.
Essential accessories shall be obtainable and/or available at every level of service delivery.

10. Custom-made and Self-made Assistive Devices

Self-made devices should be the device of choice where appropriate.
Undergraduate training curricula for rehabilitation personnel shall include training in the making and customising of certain ADs.
Clients are to be assisted to produce home-made devices out of appropriate materials.

11. Motorised Wheelchairs

A motorised wheelchair is an essential mobility device for a person who has quadriplegia/tetraplegia. Since it is an expensive device, certain criteria should be adhered to before the device is issued. The following factors shall be considered before issuing:

Resources available·Permanent disability
All limbs affected·Uninterrupted electricity at home to maintain the product
Proper training to utilise the AD correctly and the resources to maintain it correctly
Environmental accessibility
Sufficiently motivated user
Preference to be given to people who are employed or in educational institutions, or have the potential to be employed/educated

12. Augmentative and Alternative Communication

Augmentative and Alternative Communication (AAC) is used to assist with severe communication disorders in children and adults, and consists of:

dedicated computer systems
software for non-dedicated computers
computer access devices, including specially designed keyboards and voice recognition systems
other peripherals that provide adapted access to computers
computer output devices adapted for monitors and printers
computer-operated environmental control units for appliances
software programmes specific to AAC systems
switching devices

Please note: AAC should be available only at tertiary level of health care.

13. Personal Assistants

Personal assistants, such as those for the blind, people with locomotor disability, and the deaf (Sign Language Interpreters), shall be made available by institutions to assist the public to access health services.

14. Inclusions in Tenders for Assistive Devices

The guarantee period should start after the device has been issued to the client, not when the hospital receives the device.
Wherever possible, service tenders should stipulate that suppliers include the prescribed device or assistive device package, (e.g. hearing aid, ear mould, starter pack of batteries), as well as after-issue maintenance and repair, if applicable, as part of the transaction.
International tenders shall be encouraged if they ensure a more affordable product, e.g. intra-ocular lenses.
Specifications for children's wheelchairs should stipulate a 20-inch rear wheel. Set specifications should be developed.

Acknowledgemnts

The Department of Health wishes to acknowledge all individuals and organisations that contributed in the development of this guideline. The following organisations, in their capacity as members of the technical committee, played a very significant role in the development of this document:

National Council for Persons with Physical Disabilities in South Africa
National Council for the Blind
Deaf Federation of South Africa
Disability Action Research Team
Disabled People South Africa
Department of Health, Limpopo Province

To these organisations and the individuals who represented them on the technical committee, we say thank you. Without their commitment and dedication the process of developing this document would not have proceeded as smoothly as it did.

Appendix A

Acronyms

ADs - Assistive devices
AAC - Augmentative and Alternative Communication
CI - Cochlear Implantation
DART - Disability Action Research Team
DEAFSA - Deaf Federation of South Africa
DoH - Department of Health
DPSA - Disabled People South Africa
ENT - Ear, Nose and Throat
HPCSA - Health Professions Council of South Africa
NGO - Non-governmental organisation
OT - Occupational Therapist
PHRC - Provincial Health Restructuring Committee
PPP - Public Private Partnership
PT - Physiotherapist
RAF - Road Accident Fund SABS South African Bureau of Standards
SANCB - South African National Council for the Blind
SAPS - South African Police Service
SLI - Sign Language Interpreter
STA - Speech Therapist and Audiologist
TCAD - Technical Committee on Assistive Devices
UN - United Nations
WHO - World Health Organisation
WCA - Workman's Compensation Act
WPA - World Programme of Action